On the Pathology and Treatment Of Cerebral Disease
Art. III.? No. III. :Author: Robert Hunter Semple, M.D.
Fellow of the Royal College of Physicians of London. In treating of so many-sided a subject as the pathology of cerebral disease it is impossible to adopt any definite systematic arrangement, or to adhere to one particular plan of discussing the questions which present themselves to notice. The morbid phenomena of the brain involve so many derangements in other organs and tissues of the body, and, vice versa, the derangements of the latter so often induce serious cerebral symptoms, that remarks become necessarily discursive, and nosological classi- fication is practically impossible. As in many other branches of medical inquiry, too, so especially in that relating to cerebral disease, opinions are continually changing, although clinical facts and pathological appearances remain the same, and the interpretation of the two latter is varied almost to infinity according to the light in which the same conditions are viewed by different minds. Although the faculties of observation may be equal in many observers, and the opportunities of investi- gation be ample in all, yet the refinements of modern science may discover changes in the cerebral mass, which, though some may describe, others are unwilling or unable to admit, while in some cases the zeal for new discovery or for framing new theories or hypotheses will perhaps carry investigators beyond the limits of strict scientific demonstration and of logical deduction, and thus lead to the entire rejection of propositions which may contain many elements of truth. Besides this result, it is by no means infrequent to find acute and diligent workers in the field of cerebral pathology renouncing the opinions which they in former times strenuously advocated, and calling upon their disciples to join them in the repudiation of the doctrines which they themselves had inculcated.
It is difficult enough to lay down any intelligible rules for the determination of what may be called the rough pathology of the cranial contents: to distinguish, for instance, the existence of inflammation of the membranes of the brain as contra- distinguished from that of the substance of the organ; to draw the line of demarcation between simple functional disorder of it.the brain and the effects of organic disease; to determine the indications which denote an excessive supply of blood to the cerebral mass, and those which point to the opposite condition. But it is infinitely more difficult to map out the brain, as it were, into different limited regions, to assign to those special regions certain invariable functions, and to deduce from the details of symptoms the exact position of a given pathological lesion.
Some general propositions as to the functions of the different parts of the encephalic mass are admitted, but it is extraordinary how few there are which are not even now the subjects of ani- mated controversy. As the thinking principle of man is con- nected with the outer world by the means of the senses, or, in medical language, by the media of the nerves of special sense, of motion, and of sensibility, so the impairment or disease of any of these nerves will necessarily lead to corresponding dis- turbances or derangements of the functions which they perform. Disease of the optic nerves, for instance, will impair the function of sight, that of the auditory nerve will interfere with or abolish the sense of hearing, and other equally trite examples might be adduced; but when an attempt is made to trace the nerves of special sense, of motion, or of sensibility beyond the pons Varolii and to follow their fibres as they diverge into or converge from the cerebral or cerebellar fibres or con- volutions, the difficulties of investigation begin to thicken, and the region of speculation and hypothesis often replaces that of demonstration and safe deduction. It is not many years since that the doctrines of Grail and Spurzheim, although never gene- rally received by the medical profession in their full extent, were so far recognised to be true as to lead to the belief that certain regions of the brain were more or less connected with special mental attributes; and it was generally admitted that the intellectual functions had their seat in the anterior part of the brain, the moral qualities in the vertical part, and the animal propensities and passions in the posterior portions. But as the mock physician in Moliere’s Medecin malgre lui ” says, ” Nous avons change tout cela,” and it is now commonly asserted that while the anterior lobes of the brain preside over the functions of intelligence, the middle lobes, comprising the cen- tral and upper lobes, are the portions connected with the motor powers, and the posterior part of the brain is especially con- nected with sensation. This view is, however, by no means universally admitted.
In order to understand correctly the divisions of the brain as defined by the modern school of psychological anatomists, it is necessary to examine the organ in a different manner to that which was until recently taught in the dissecting room. Every student and practitioner of medicine is of course aware of the obvious division of the cerebrum into two lateral hemispheres ; the subdivision of each hemisphere into two unequal parts by the fissure of Sylvius; the union of the two hemispheres by the corpus callosum; the separation of the cerebrum from the cerebellum by the tentorium; and the union of these two brains by means of the pons Varolii and the crura cerebri and cerebelli. But modern research points out other marks of division which would escape the notice of the superficial observer, and which were certainly never taught in former years in the schools of medicine. Thus, for instance, the division between the anterior and middle lobes, formerly described as being only imperfectly established by the fissure of Sylvius, is now said to be completed by a furrow proceeding upwards in an oblique direction from the above-mentioned fissure to the vertex, and named the fissure of Rolando, while the division between the middle and posterior lobes, formerly regarded as merely nominal, is said to be estab- lished by another furrow, which has not, however, received a distinct appellation. Moreover, the convolutions of the anterior lobe, which were not formerly regarded as admitting of any distinct classification or definite arrangement, are now grouped in three series, from before backwards, or from behind forwards, from the anterior part of the longitudinal fissure to the fissure of Sylvius, or vice versa, and named respectively the first, second, and third frontal convolutions ; and the parietal, temporal, and occipital convolutions are likewise divided into numerically distinguished groups.
The significance and importance of these anatomical divisions have been recently greatly enhanced by some striking observa- tions on the pathology of aphasia, first recorded by M. Broca, and by the still more recent and more striking and even start- ling researches and experiments, made especially on monkeys, by Dr Ferrier. It is pretty generally known that M. Broca, from the examination of two brains in the Bicetre Hospital in Paris, was led to localise the function of speech in the third frontal convolution of the left side, and many subsequent inves- tigations on the clinical history and morbid anatomy of aphasia have more or less confirmed his opinion. It is perhaps even more generally known that Dr Ferrier, in a most interesting series of inquiries, has demonstrated the fact that stimulation of certain portions of the cortical substance of the brain was followed in his hands by definite movements on the part of the animal experimented upon, those portions being chiefly situated in the anterior part of the organ. Dr Ferrier, indeed, makes a rough division of the brain into a sensory and motor part, by PATHOLOGY AND TREATMENT OF CEREBRAL DISEASE. 241 drawing a line through the fissure of Sylvius obliquely back- wards and upwards to the extreme termination of the parieto- occipital fissure, all the motor region being placed by him above and in front of this line, and all the sensory region being behind and below it.
Adhuc sub judice lis est; and notwithstanding the high authority of M. Broca, and the scientific skill and trust- worthiness of Dr Ferrier, it would be, perhaps, premature to receive the results obtained by either of these distinguished physiologists into the category of acknowledged truths; and, indeed, as I write, a formidable antagonist has presented himself from the very ranks which might have been expected to corro- borate the statements and confirm the deductions of their French and their British confrere. No less an authority than Dr Brown-Sequard, who has, perhaps, done more than any living investigator to localise the functions of the brain, now publicly announces, in his “Lectures” before the Royal College of Physi- cians of London, that his own previous results are fallacious, and that the brain acts as a whole, and not by the separate agency of its individual parts.
Dr Brown-Sequard has at present only developed the out- lines of his recent views, and there may be some risk of mistak- ing his meaning; but, in order to avoid error, I copy almost literally from his own acknowledged writings,f and I find him stating that there is no necessary relation between the seat, the extent, the kind of a cerebral lesion, and the symptoms that may appear from its influence. He proceeds, in the same published lecture, to enunciate in a categorical form a series of proposi- tions which are founded on experience, and the truth of many of which must at once be acknowledged. Thus, for instance, he says: (1) That a lesion in one half of the brain may pro- duce symptoms either on the opposite or on the corresponding side; (2) That a very small lesion, whatever be its seat, may produce most violent and extensive symptoms; (3) That a lesion occupying the same extent on the two sides of the middle line of the brain may produce symptoms only, or chiefly, on one side of the body ; (4) That symptoms may proceed slowly from a suddenly produced lesion ; (5) That symptoms may appear suddenly from a slowly and gradually developing lesion; (6) That the greatest variety of symptoms may proceed from a lesion in the same part of the brain; (7) That the lesions of the most various parts of the brain may give rise to the same symptoms ; (8) That permanent lesions may produce symptoms
” On the Localisation of the Functions of the Brain,” by Dr Ferrier.
British Medical Journal, December 19, 1874. t “Lectures,” by Dr Brown-Sequard. Lancet, July 15, 1876.
by attacks just as they produce epileptiform seizures; (9) That symptoms may cease suddenly or rapidly, notwithstanding the persistence of the lesion; (10) That symptoms of brain disease may appear from irritation of visceral and other peripheric nerves; and (11) That considerable lesions anywhere in the brain may exist without the appearance of any symptoms. In some former papers I have adduced cases and post- mortem examinations from my own personal experience, which remarkably confirm some of the above propositions, and I now adduce some others which more or less illustrate the truth of the views here and elsewhere expressed.
The following is a good illustration of the statement that permanent disease affecting the brain may produce symptoms which are in their nature essentially intermittent. It is, in fact, a typical case of epilepsy, caused by thickening of the internal table of the skull and exostoses of its processes; and it will be observed that the patient was watched for several years during life, and that the morbid parts were accurately examined after death.
Case.?M. Y., set. 46, formerly a servant, was obliged to leave her place many years ago in consequence of frequent attacks of epilepsy. She was an inmate of an infirmary which I attended, and I saw her repeatedly during many years, as she was under constant medical treatment; the fits were frequent, occurring at irregular intervals, and of a very violent character. In the intermissions between the fits her health was tolerably good, with the exception of occasional headache ; her intel- lectual faculties were quite unimpaired. As she always derived benefit from the local abstraction of blood, her disease was con- sidered to be of a congestive character, and a strict antiphlo- gistic regimen was adopted and maintained. She was on several occasions cupped between the shoulders, blisters were applied and kept open in the same situation, and occasional purgatives were administered. Her diet was of the lightest character; no solid food or beer was allowed, and she derived her sustenance entirely from milk, eggs, bread, and thin broth or beef tea. This treatment was continued, as I have mentioned, for several years and with some advantage, but no decided im- provement in preventing the fits. These at last became more frequent and severe, symptoms of low fever supervened, and she sank.
It should be mentioned that she was in all respects a well- conducted woman, had never been addicted to drink or any other vice, and indeed had been a domestic servant of perfectly good character, until she was attacked with illness. The post-mortem examination was made forty-three hours PATHOLOGY AND TREATMENT OF CEREBRAL DISEASE. 243 after death, and the body was found to be plump and well- formed, and there was a layer of fat beneath the skin, about three-quarters of an inch in thickness : certainly a remarkable fact, considering the tenuity of her diet, which had been always strictly regulated.
The scalp was natural. The skull externally presented no peculiar appearance, and I had no difficulty in sawing it through. On removing and examining it, however, it was found that there existed a remarkable want of uniformity between the two surfaces of the cranium in some parts, owing to thickening of the osseous structure, particularly of the internal table, which, instead of being, as usual, thin and brittle, was thick and solid. Along the line of the circular incision, made as usual by the saw, the skull was of about the average thickness. The os fron- tis was then sawn through immediately in front of and in a line corresponding with the coronal suture. Along the circular line of incision made by the saw in the first instance in re- moving the calvarium, the skull had a uniform thickness of one line and a half; but the part corresponding to the right frontal eminence was half an inch thick, and the same part on the left side was five lines in thickness. All the prominent bony pro- cesses were much increased in thickness and asperity, as the crista galli, the posterior clinoid processes, the bony ridge of the petrous portion of the temporal bone, the ridges on the in- ternal surface of the occipital, etc. The dura mater was con- gested ; the vessels of the arachnoid membrane were also congested, and the membrane itself was opaque and thickened; beneath the arachnoid there were two or three fluid drachms of bloody serum. The brain was flattened in front, the depression exactly corresponding to the thickness of the internal table of the skull. The substance of the brain was very firm in its consistence, and the grey part was of an unusually dark colour, but otherwise it presented no peculiar appearance or alteration of character. The other organs of the body were examined in order to make the investigation complete, but no remarkable appearances were anywhere detected.
The above case is a remarkable one, and, after long reflec- tion, I can come to no other conclusion than that the pathology was as I have stated it to be. It is, of course, remarkable that the morbid condition being the same, the attacks were inter- mittent, but the fact is in accordance with the eighth proposi- tion laid down by Dr Brown-Sequard and quoted in a previous page. I may also remark, en passant, that the treatment was probably the best that could have been pursued, and that any experimental therapeutics, either in the way of specifics or of great depletion, or of undue stimulation, would have been not only useless but very likely might have been very mischievous. The following very curious but successful case, which I watched myself daily and almost hourly, and of which I made careful notes, is an instance of local disease of the brain, the seat being indicated by the symptoms, and the treatment being justified by the recovery of the patient. I may also state that I knew the condition of the patient long before and long after the attack, so that the features of the case are complete. The malady evidently affected the fifth pair of cerebral nerves on the right side.
Case.?E. B., set. 54, a healthy looking woman, has gene- rally enjoyed good health, with the exception of suffering occasionally from indigestion, and once, two years ago, from an attack of pneumonia. About six weeks from the date of the present report, she first experienced slight dimness of sight in the right eye, which, however, on examination did not present any peculiar appearance. At that time she also complained of a pricking, shooting pain in the same eye, together with pain in her forehead, face, and right ear. As no morbid appear- ance could be detected and no distinct derangement of health was apparent, she was merely recommended to bathe the eye with cold water, which, however, did not afford any relief. Since that time the pain has become gradually worse, and her health has been much impaired.
The sufferings becoming now very much aggravated, a care- ful examination was made of the symptoms and the appearances, which were as follow : She complains of a shooting, throbbing, burning pain in the right eye, and a sensation, as she expresses it, as if the eyeball were too large for its socket. The same kind of pain extends to the forehead as far as the vertex, backwards to the ear and occiput, and down the neck; to the right side of the nose as far as the external aperture of the right nostril, and to the upper maxillary bone, the pain originating at the situa- tion of the infra-orbital foramen. The upper eyelid is completely drawn over the ball of the right eye, so as completely to obstruct vision. She has no power to lift it up, and the attempt made by me to draw up the lid causes excruciating pain and violent action of the orbicularis palpebrarum which immediately draws down the lid again. The falling of the lid, therefore, is not owing to palsy of the levator palpebrae superioris, but to spasmodic con- traction of the orbicularis palpebrarum. When the lid is elevated, although this is done with great difficulty, she is able to see very distinctly. There is, therefore, no disease of the optic nerve, or of any of the internal structures of the eye-ball, the only peculiar appearance presented by the eye being that the pupillary aperture is oval instead of round. This last appearance is no doubt due to some sympathetic affection of the lenticular ganglion, which supplies the iris with nerves, and which, as is well known, receives a small nervous thread from the nasal branch of the first or ophthalmic division of the fifth pair. She says that since her illness her hearing on the right side has been impaired?a circumstance due, no doubt, to sympathetic affection of the auricular branches of the third division of the fifth pair, or of the chorda tympani which joins the gustatory nerve. The power of smelling and of taste are, however, quite perfect. The pain in the parts above described is not constant, but subject to violent exacerbations and remissions, and is much increased by pressure on the affected regions. She complains of derangement of her general health, has a sour taste in the mouth, has no thirst, nor any desire for food ; she has vomited several times this morning (day of examination); bowels moderately open ; urine scanty and high-coloured; tongue covered with a white thick fur ; pulse 84, regular. At first I thought the case to be one compounded of neuralgia, dyspepsia, and perhaps hysteria, but its progress soon convinced me that the disease was definitely seated in some part of the brain, and that it affected the origin, and not the extremities of the nerves. Acting on my first impression at the commencement, I ordered a blister to be applied to the right temple, and some alterative and aperient medicine to be administered. Oct. 15 (two days after this treatment was adopted) : Feels rather better, and on the whole the pain is somewhat diminished. She can lift the right upper eyelid to the extent of about a quarter of an inch, but with pain and great effort. The eyelid is very tender to the touch. The general health is much improved ; tongue much cleaner, but still slightly furred; vomiting has ceased ; bowels open ; no sour taste in the mouth ; pulse 84, regular. Oct. 16.?Feels much worse; has had no sleep the whole of last night in consequence of excessive pain in the parts above described. As I now believed that there was some inflammatory or congestive affection within the brain affecting the origin or the course of the fifth pair of nerves, I ordered five grains of pilula hydrargyri to be taken twice a day, and an aperient draught every four hours containing some tartrated antimony.
7 p.m. same day.?She has taken two doses of the medicine: the first produced no marked effect; the second excited copious vomiting, followed by a violent convulsive fit, attended with foaming at the mouth. On my visiting her soon after this attack, she was lying in a state of torpor, and could not answer the questions put to her. I could now lift up the right eyelid without apparently exciting any pain, but the eyeball was drawn in different directions by the convulsive action of the recti and obliqui muscles. The pupil contracted and dilated, but its margin was irregular, assuming a somewhat triangular shape; pulse 100, strong and incompressible. I now bled her, and while the blood was being drawn she was seized with violent attacks of rigidity of all the muscles, but they ceased after last- ing a few minutes. She appeared now to be only partially sensible, groaned occasionally, and drew her breath heavily and laboriously. 11 p.m. same day.?Breathing now hardly per- ceptible, except at intervals, when she takes two or three deep inspirations. There is constant rigidity of both lower extremities; the upper extremities are also rigidly fixed, although they are now and then relaxed for a short time. The lower jaw is firmly closed, and any attempt to draw it down is opposed by the violent contraction of its muscles. The muscles of the face are not rigid, and both the lips and eyelids can be freely drawn in any direction. The pupil of the right eye varies very much in figure, but is never round. There is not much spasm of the muscles of the back or abdomen, although both appear slightly rigid when pressed upon; pulse 80, soft and compressible. Oct. 17.?The rigidity of the muscles has continued with intermissions throughout the night, during a part of which she was delirious. Blood drawn yesterday, not buffed nor cupped ; pulse 80, soft. Since 7 o’clock this morning she has been sensible ; and she now answers questions quite rationally. She has now perfect power over all the voluntary muscles, except that she is still unable to raise the right eyelid. The pain caused by the attempt to draw it up with my finger is more intense than formerly: tongue dry, and covered with fur; no thirst; skin dry ; bowels not relieved since six o’clock last night; lias passed no urine for twenty-four hours; breathing natural. The following plan was now adopted: a solution of the extract of belladonna (gr. v. to sj of water) was dropped into the eye, poured upon the blistered surface on the right temple, and applied to the whole of the right eyelid and adjacent parts by means of a linen rag. She was also ordered to take every four hours a pill containing three grains of blue pill and two of calomel. In three minutes after the application of the solution of belladonna, as above described, the pain in the eyeball ceased, and she expressed it as being benumbed.
Oct. 18.?Feels rather better. The fits of spasmodic ri- gidity occurred last night nearly every ten minutes, but they ceased at 1 a.m., and after that time she had some tranquil sleep. She is now quite sensible, and has passed about a pint of urine, which has deposited a copious white sediment. The pain in the eyeball is less: she says it is benumbed, but expo- sure to light gives considerable pain; there is pain in the left lumbar region; bowels confined; pulse 7 6, rather hard. To have half an ounce of castor oil immediately, and to continue the pills of calomel and blue pill.
8 p.m. same day.?Feels much better, and the pains are much relieved. The right eyelid can be lifted up without much suffering, but she cannot raise it by her own exertions. The bowels have been opened, and the stools are copious; she has passed urine ; pulse 80, soft and compressible ; she is now quite sensible. She has had three spasmodic fits since the morning, but they lasted a very short time.
Oct. 19.?Improving; has had no spasms since the last visit; has slept from two till six o’clock this morning; the pain in the right eyeball and eyelid is diminished, and these parts are less tender on pressure: the attempt to raise the lid by the finger is also less opposed by the action of the muscle, but she is still unable to raise it herself; pulse 80, soft and full; gams rather tender. The solution of belladonna was again applied to the blistered surface of the right temple. To continue the pills. Oct. 20.?Considerably improved; she has had no spasms during the night; the pain is relieved, and she does not now suffer any inconvenience in any part of the body ; the eyelid is still drawn down, and the tenderness of the eyeball remains, but not so remarkably as before. As her gums were sore she was now directed to discontinue the pills, and to take some aperient and diuretic medicine.
Under this treatment she rapidly improved; the secretions became natural, the tenderness of the eyeball wholly disap- peared, and she regained the perfect power of raising the lid. ?Shewas discharged cured on the 26th November; and although I had frequent opportunities of seeing her for many months afterwards, she had no return of her complaint, and went on pursuing her ordinary avocations.
I think there can be very little doubt that the above case was one of local disease of the brain, the locality being denoted by the symptoms. Whatever the malady may have been, it appears to have involved the origin of the fifth pair of nerves on the right side. It will be observed that all the parts sup- plied by the ophthalmic branch of this nerve were acutely painful, and that the pain was also traced to the parts supplied by the superior maxillary nerve; the motor part of the inferior maxillary nerve was also affected, as was proved at one period of the disease by the spasmodic closure of the jaws. The pain and spasm in other parts of the body are, of course, explicable by the reflex action of the spinal cord and medulla oblongata. That it was not mere neuralgia is, I think, proved by the incessant pain and tenderness of the parts supplied by the ophthalmic nerve, by the general course of the symptom?, and by the decided benefit afforded by antiphlogistic measures. It could not have been a case of hysteria, the patient exhibiting no indications whatever of that complaint, and the malady both coming on and going off gradually. Again, it is evident that the symptoms were not caused by any organic disease of the brain, or by any tumour or spiculum of bone, for the cure was complete, and I saw her for months before and after the attack. Nor could they be due to inflammation of the brain, for the state of the pulse, the absence of heat in the head, and other obvious considerations, preclude that supposition. On the whole, I am inclined to believe that it was a case of local congestion, which yielded to the treatment adopted. The ultimate aim and object of medicine being to relieve the sufferings of the patient, and not merely to discuss the nature of the disease under which he is labouring, I now offer some ge- neral observations on the treatment of cases such as those above detailed. I do not at present refer to the treatment of inflam- mation of the brain, or of those various conditions to which the term apoplexy is usually applied. To the pathology and treatment of the latter class of cases I have already briefly referred in former papers.
There are a great number of cases more or less obscure in their pathology, which point to some morbid condition in the intracranial structures, but to which no general designation can be attached, and which are often remediable by careful and judicious treatment. To take only the two cases recorded in the present paper, one was an instance of hypertrophy of the cranial bones, especially of the internal table of the skull and of the bony processes, and the other was in all probability an example of local congestion, but producing the most serious general as well as local symptoms. Such cases might, of course, be due to, and might often be mistaken for, organic diseases of the brain, which are in their nature incurable; and, on the other hand, they might, with equal probability, be attributed, until the features of each case were thoroughly known, ex- amined and compared, to mere transient functional derange- ment, which would give way to any treatment or to no treat- ment at all. Hence the utmost caution is necessary, in the first place, in order to ascertain, if possible, the nature of the affec- tion ; and it is better to wait for some time watching the course of the malady before beginning any decided mode of treatment, because the symptoms may possibly give way of themselves, and premature medication might unjustly arrogate to itself the be- neficial results which are really due to the operations of nature. This rule, it will be seen, was observed by me in the second case recorded in this paper, for the patient was carefully watched for six weeks, and decisive treatment was not commenced until the symptoms were so severe and so well marked as to call im- peratively for active interference.
The theory of localisation of function in the brain, whether true or false, does not throw much light upon, or lead to much practical benefit in, the treatment of cerebral diseases. In ma- naging such affections the organ must be considered as a whole, and remedial measures must be calculated to act upon it through the general system. Even when the disease is local- ised, as it very often is, it must be combated, as is frequently done very successfully, by specific or general therapeutical measures acting upon the whole of the cerebral structures. A very careful enquiry must always be made, in any given case, as to the antecedents of the patient and as to the family history. Putting aside, for the present, the consideration of inflam- mation of the brain or its membranes, and of the various con- ditions giving rise to apoplectic extravasations and to softenings, there is little doubt that many, if not most, of the other morbid states of the organ are due to, or connected with, some constitu- tional or hereditary predisposition; and that gout, rheumatism, scrofula, syphilis, and cancer, lie at the root of many of the obscure cerebral maladies with which the physician has to deal. Sometimes one or other of the constitutional affections just referred to has openly manifested itself during the patient’s life, and then the diagnosis is very materially assisted; but in other cases the fons et origo mail perhaps remains in a latent state during the whole of life, and the real nature of the case is detected only on a post-mortem examination. How often does it happen, however, that a new and unexpected light is thrown upon an obscure cerebral disease of long standing by the sudden appearance of some gouty affection of the smaller joints; and how often, too,does the persevering administration of some specific remedy cause the disappearance of perplexing cerebral pheno- mena. Modern pathology has shown in a very satisfactory manner that most diseases (omitting, however, fevers and other so-called zymotic maladies) are due not to accidental or avoid- able causes, but to constitutional predisposition or to the operation of some poison latent in the system. In some cases the materies morbi has been acquired by the habits of the patient himself, but in many others it has been inherited by him from his ancestors, even a generation sometimes intervening between the original taint and its repetition in the person of the grandchild.
Without going to the extreme lengths advocated by some specialists, it is lamentably true that the syphilitic poison, for instance, may develop itself in an active form, and even go so far as the destruction of the bony tissues, in adults who have never themselves suffered from syphilis; and I have myself seen too many such cases to doubt the reality of their existence. It is true that in persons of 20 years of age or thereabouts, of either sex, it is exceedingly difficult to prove a negative in such matters, but by tracing cases, as I have done, at various ages, from early infancy to adult age, and by observing and compar- ing the very same phenomena in the young child, in the elder child, and in the adult, and giving a certain weight (as is only fair) to moral considerations, it is, I think, unquestionable that syphilitic disease may and often does develop itself in many persons who are quite innocent themselves of having ever run the risk of acquiring the malady. Of course I here allude to what are called the constitutional phenomena of syphilis, and not to the primary manifestations.
These observations are made in connexion with the treat- ment of several obscure diseases of the brain characterised by anomalous symptoms ; and probably in the cases where decided benefit has resulted from the long-continued and liberal ad- ministration of the iodide of potassium, or . of small doses of the perchloride of mercury, either taken together or separately, the origin of the case has been of a syphilitic nature. I re- member one remarkable case which I attended, in which very severe cerebral symptoms, apparently pointing to some pres- sure upon the brain, gave way to the long-continued use, in large doses, of the iodide of potassium. I recollect another, where the same salt caused the disappearance of some conges- tion about the root of the third nerve (as indicated by para- lysis of the levator palpebrse superioris of one eye) and restored the patient to health. Another very good illustration is, I think, afforded by the result of the treatment in the second case recorded at full length by me in the present paper, and in which there was evident congestion about the root or the course of the fifth pair of nerves.
I do not, however, for a moment allege or suppose that all such cases have a syphilitic origin; all I contend for is that the possibility of such connexion should be borne in mind in the study of doubtful cases, and, especially where other means have failed, that the efficacy of specific treatment should be tested. I may remark that the effects of constitutional syphilis on the brain or the cranium might consist of exostoses of the cranial bones, or of gummatous formations in the brain itself, and experience teaches that these conditions may be remedied by the use of iodine and mercury.
But there are other maladies, besides syphilis, which may give rise to cerebral disturbance, and perhaps one of the most prominent of these is gout, an affection which, like syphilis, may be acquired or inherited, and which is also alike amenable to medical treatment. As in the case of syphilis, the origin of the gouty affection may be obscure, in the absence of all the usual local manifestations, and perhaps the only light thrown upon the case may be in consequence of the successful use of appropriate remedies. As general hints in the diagnosis of such cases, however, I may observe, in the first place, that gout is far more common in the rich and well-to-do classes than among the poor, and hence cerebral disease of a gouty origin is not often observed among the latter; and, secondly, that a careful examination, chemical and microscopical, of the urine ought always to be made, when the undue acidity of the fluid or the presence of uric acid crystals will afford valuable assistance in diagnosis. Supposing, then, that the history or the circumstances of the case point towards gout, it will be advisable to administer colchicum in moderate and repeated doses, together with alkalies, more especially potash and lithia, as these are the solvents of uric acid; and to prescribe change of air and exercise for the patient, and to enjoin a strict system of diet.
Of the treatment of the cerebral diseases due to the strumous or the cancerous cachexia there is but little to be said. The former category of cases would derive benefit from such well-known remedies as are known to modify in a favourable direction the strumous diathesis, such as cod-liver oil, iron, quinine, generous diet, fresh air, sea-bathing, marine travelling. The category of cancerous affections affords but little hope as to the success of any remedial measures. But it is to be remembered, as I have before observed, that the actual existence of malignant disease in the brain can in most cases, in the living body, be only a matter of conjecture, and it may always be hoped that the malady is of a less formidable character. Hence the treatment should be directed towards the other constitutional ailments to which I have adverted, and there are few observant practitioners who have not found in many cases that the most serious symptoms have given way to therapeutic measures, and the fears of the existence of malignant disease have been happily dissipated. The very circumstance of the doubtful character of many cerebral diseases gives reason to hope for a favourable result, and this result is by no means so rare as is sometimes imagined.
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